Sleep Solution for Magellan Complete Care of Virginia Members

Provider Training Program for Sleep ManagementPresented By:

Sleep Disorders

Our Program

1. Magellan Healthcare’s Sleep Solution

2. Prior-Authorization Program

3. Clinical Information Request and Review

4. Prior-Authorization Process

5. Notification of Determination

6. Network Approach

7. Provider Tools and Contact Information

Questions and Answers

Magellan Healthcare1 Program Agenda

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1National Imaging Associates, Inc. is a subsidiary of Magellan Healthcare, Inc.

Sleep Disorders

Sleep Disorders can exacerbate medical issues resulting in increased healthcare utilization when left untreated

• Untreated sleep disorders can contribute to worsening of medical conditions such as heart disease, high blood pressure, diabetes, etc.

• The impact of sleep disorders is gaining wider recognition• Obstructive Sleep Apnea (OSA) affects 15 - 30 million people in the United

States and is the most prevalent sleep disorder• Other disorders include narcolepsy, periodic movement disorder, restless

leg syndrome, parasomnia, etc.

Magellan Healthcare’s Sleep Solution

• Addresses growing demand for sleep-related services.

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Magellan Healthcare’s Sleep Solution for Magellan Complete Care of Virginia

• Manages utilization of sleep tests‒ Ensures appropriate use of polysomnography based on clinical

guidelines‒ Reduces unnecessary repeat studies‒ Encourages sleep assessments when needed due to the potential for

other medical co-morbidities

• Promotes appropriate assessment setting‒ Supports facility-based testing when appropriate

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Magellan Healthcare’s Prior Authorization Program

• Diagnostic Imaging –MR, CT/CTA, PET, CCTA, Nuclear Cardiology/MPI, Stress Echo, Echocardiography

• Cardiac Interventions Catheterizations and Implantable Devices

• Musculoskeletal (MSK) Procedures • Interventional Pain Management-

Spinal Epidural InjectionsFacet Joint InjectionsFacet Joint Denervation/Neurolysis

• MSK Surgery– (Inpatient and Outpatient)Lumbar MicrodiscectomyLumbar DecompressionLumbar Spine Fusion (Arthrodesis) Cervical Anterior Decompression with Fusion –Single & Multiple Levels Cervical Posterior Decompression with Fusion –Single & Multiple LevelsCervical Posterior Decompression (without fusion)Cervical Artificial Disc ReplacementCervical Anterior Decompression (without fusion)

• Radiation Oncology Management All Radiation Therapy for All CancerAll Other Conditions using Intensity Modulated Radiation Therapy Stereotactic Radiation Therapy and Proton Beam

• Sleep Studies

August 1, 2017Only non-emergent procedures performed in an outpatient setting (with the exception of Inpatient Musculoskeletal (MSK) Surgeries) require prior authorization with Magellan Healthcare

Procedures Requiring Prior Authorization

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Excluded from Program:Procedures Performed in

the Following Settings:

• Hospital Inpatient (excluding MSK Surgery)• Observation• Emergency Room/Urgent Care Facility

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Sleep Management for Magellan Complete Care of Virginia• Magellan Healthcare’s sleep solution for MCC VA manages attended sleep

assessments and treatment initiation/management services using prior authorization and clinical reviews

• The MCC-VA program does NOT manage home sleep tests (because this is not a covered benefit) or sleep treatment devices (e.g. CPAP machines)

Authorized CPT Code

Description Allowable Billed Groupings

94660 Sleep disorder treatment initiation and management

94660

95811 Sleep study, attended 95782, 95783, 95805, 95807, 95808, 95810, 95811

List of CPT Procedure CodesRequiring Prior Authorization

• Review Claims/Utilization Review Matrix to determine CPT codes managed by Magellan Healthcare

• CPT Codes and their Allowable Billable Groupings

• Located on RadMD

• Defer to Magellan Complete Care of Virginia’s Policies for Procedures not on Claims/Utilization Review Matrix

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INSERT HEALTH PLAN SPECIFIC MATRIX SCREEN SHOT

Responsibility for Authorization

Ordering Provider

Responsible for obtaining prior authorization

Rendering Provider

Ensuring that prior authorization has been obtained prior to providing service

Recommendation to Rendering Providers: Do not schedule test until authorization is received

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Prior Authorization Process Overview

Ordering Physician

Telephone Magellan

Healthcare Magellan’s Call

Center

Online Through RadMD

www.RadMD.com

Algorithm

Service AuthorizedRendering Provider

Performs ServiceClaim

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Prior Authorization Process Overview

Ordering Physician

Algorithm

Service AuthorizedRendering Provider

Performs ServiceClaim

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Submit Requests by Phone

Or Online Through RadMD

www.RadMD.com

Information evaluated via algorithm and medical records

NIA’s Clinical Foundation & Review

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Peer-to-Peer Discussion

Clinical Review by NIA’s Specialty Clinicians

Fax/Upload Clinical Information (upon request)

Clinical Algorithms collect pertinent information

Clinical Guidelines Are the Foundation

Clinical guidelines were developed by practicing specialty physicians, literature reviews, and evidence base. Guidelines are reviewed and mutually approved by Magellan Complete Care and Magellan Healthcare Chief Medical Officers and clinical experts

Algorithms are a branching structure that change depending upon the answer to each question

When requested, the patient’s medical record will be required for validation of clinical criteria before an approval can be made

NIA reviews key clinical information to ensure Magellan Complete Care of Virginia members are receiving appropriate care based on their clinical condition

Peer-to-peer discussions are offered for any request that does not meet medical necessity guidelines. Our goal –ensure that Magellan Complete Care members are receiving appropriate care

Patient and Clinical Information Required for Authorization

GENERAL

Includes things like ordering physician information, Member information, rendering provider information, requested examination, etc.

CLINICAL INFORMATION• Clinical information needs to explain the

need for an attended sleep test, including:─ Patient symptoms, relevant patient

characteristics, patient’s current status and physical exam findings.

─ Screening test results or reports from other diagnostic tests; if request is due to a failed Home Sleep Test, include documentation of results and issues.

─ Contraindications to a Home Sleep Test, including the patient’s relevant medical history.

Refer to the Prior Authorization Checklists on RadMD for more specific information.

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Requesting Clinical Information

• NIA may request patient’s medical records/additional clinical information

• Providers may either submit medical records or contact our Nurse Reviewer with additional clinical information

• Medical records are preferred and are easy to upload via RadMD

• Helps ensure that patients receive the most appropriate, effective care

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Magellan Healthcare to Ordering Provider: Request for Additional Clinical Information

• A fax is sent to the provider requesting medical records, along with a Fax Coversheet

• We stress the need to provide the clinical information as quickly as possible so we can make a determination

• Determination timeframe begins after receipt of clinical information

• Failure to receive requested clinical information may result in non certification

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Submitting Additional Clinical Information/Medical Records to Magellan Healthcare

• Two ways to submit clinical information to Magellan Healthcare

‒ Via Fax

‒ Via RadMD Upload

• Use the Fax Coversheet (when faxing clinical information to Magellan Healthcare)

• Additional copies of Fax Coversheets can also be printed from RadMD or requested via the Call Center @ 1-800-424-4524

Be sure to use the Magellan Healthcare Fax Coversheet for all transmissions of clinical information!

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Prior Authorization Process

Intake level Initial Clinical Review

• Requests are evaluated using our clinical algorithm

• Requests may:

1.Approve

2.Require additional clinical review

3.Pend for clinical validation of medical records

• Nurses will review request and may:

1.Approve

2.Send to Magellan Healthcare ‘s physician for additional clinical review*

• Physicians may:

1.Approve

2.Deny

Physician Clinical Review

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A peer to peer discussion is always available!

Notification of Determination

• Authorization Validity Period

• RBM, IPM, MSK Surgery, Cardiacand Sleep - 90 days from the date of the request Radiation Oncology = 180 days from the date of the request

• Denial Notification

• Appeal Instructions

• In the event of a denial, providers are asked to follow the appeal instructions provided in their denial letter

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• Approval Notification

Magellan Healthcare’s Re-review and Urgent/Expedited Authorization Process

Re-review Process

• Re-Reviews will be allowed within 5 business days of initial denial determination

Urgent Authorization Process• If an urgent clinical situation exists outside of a hospital emergency room,

please contact Magellan Healthcare immediately with the appropriate clinical information for an expedited review 1-800-424-4524

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Provider Network:

• Magellan Complete Care of Virginia will use their network of sleep assessment Providers/Facilities for delivering Sleep Management services to Magellan Complete Care of Virginia’s membership

Using Magellan Complete Care of Virginia’s Network

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Claims

• Rendering providers/Imaging providers should send their claims directly to Magellan Complete Care of Virginia.

• Providers are strongly encouraged to use EDI claims submission.

• Check on claims status by logging on to the Magellan Complete Care website at: www.mccofva.com

Claims Appeals ProcessHow Claims Should be Submitted

• In the event of a prior authorization or claims payment denial, providers may appeal the decision through Magellan Complete Care of Virginia

• Providers should follow the instructions on their non-authorization letter or Explanation of Payment (EOP) notification.

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Provider Tools

Provider Tools that Make it Easy for Providers to Partner with Magellan Healthcare

• Toll free authorization and information number 1-800-424-4524

• Available Monday – Friday 8am – 6pm EST

• Interactive Voice Response (IVR) System

• RadMD Website – Available 24/7 (except during maintenance)

• Different functionality for ordering and facility/place of service providers

• Request authorization and view authorization status

• Upload additional clinical information

• View Clinical Guidelines, Frequently Asked Questions (FAQs), and other educational documents

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Ordering Provider: Getting Started on RadMD.com

STEPS:

1. Click the “New User” button on the right side of the home page.

2. Select “Physician’s office that orders radiology exams”

3. Fill out the application and click the “Submit” button.

• You must include your e-mail address in order for our Webmaster to respond to you with your Magellan Healthcare-approved username and password.

NOTE: On subsequent visits to the site, click the “Sign In” button to proceed.

1Everyone in your organization is required to have their own separate user name and password due to HIPAA regulations.

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Rendering Provider: Getting Started on RadMD.com

STEPS:

1. Click the “New User” button on the right side of the home page

2. Select “Imaging Facility or Hospital that performs radiology exams”

3. Fill out the application and click the “Submit” button.

• You must include your e-mail address in order for our Webmaster to respond to you with your Magellan Healthcare-approved username and password.

NOTE: On subsequent visits to the site, click the “Sign In” button to proceed.

IMPORTANT

• Everyone in your organization is required to have their own separate user name and password due to HIPAA regulations.

• Designate an “Administrator” for the facility who manages the access for the entire facility.

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Dedicated Provider Relations Contact Information

Magellan Healthcare Dedicated Provider Relations Manager:

Name: Charmaine S. Everett

Phone: 1-800-450-7281 ext. 32615 or at (410) 953-2615

Email: cseverett@magellanhealth.com

Providing educational tools to Medical Specialty Ordering Providers and Facilities on processes and procedures.

Magellan Complete Care of Virginia provider Service Department

Phone: 1-800-424-4524

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Confidentiality Statement for Providers

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The information presented in this presentation is confidential and expected to be used solely in support of the delivery of services to Magellan Complete Care of Virginia members. By receipt of this presentation, each recipient agrees that the information contained herein will be kept confidential and that the information will not be photocopied, reproduced, or distributed to or disclosed to others at any time without the prior written consent of Magellan Complete Care of Virginia and Magellan Health, Inc.

Thanks